Comparison of US Bilateral Erector Spinae Plane Block, US Bilateral Quadratus Lumborum Block and Lumbar Epidural for Postoperative Analgesia in Patients Undergoing Total Abdominal Hysterectomy

To perform ESP block in the lateral position bilaterally ,the skin will be disinfected with 70% alchol bilaterally and a linear transducer is placed in a longitudinal parasagittal orientation and erector spinae muscle, trapezius muscle, rhomboid major muscle (rhomboid major muscle is absent below T6 level) and transverse process are visualized and local anesthetic is injected (0.25% bupivacaine 20 ml in each side) in the area between transverse process and erector spinae muscle at T10 level.

In the lateral decubitus position. Right block will be performed; the patient will then repositioned for the left block. An ultrasound device with a convex probe (5-8 MHz) will be placed in the mid-axillary line just above the iliac crest. Then, scan dorsally to keep the transverse orientation until seeing the aponeurosis of the transverses abdominus muscle and by following this aponeurosis, QL muscle will be visualized with its attachment to the lateral edge of the transverse process of the L2 vertebral body and visualize the thoracolumbar fascia at the lateral edge of the QL muscle. A spinal needle (20G) will be inserted in-plane from the anterior to posterior direction, and the tip of the needle will be advanced anterior to the QL muscle. The target site for injection is the plane between the quadratus lumborum and psoas major muscles. This will be followed by injection of 0.25% bupivacaine 20 ml in each side.

"under strict aseptic precautions, lumbar epidural was performed for patients in Group III using a 16-gauge Touhy epidural needle by a median approach. The T12 - L1 or L1 - L2 interspaces was chosen for the injection.~The epidural space identified by the loss of resistance technique. The catheter was advanced 4 cm cephalad. When the aspiration test results for blood and cerebrospinal fluid were negative, a test dose of (3 mL) 2% lidocaine with 1: 200,000 adrenaline was given after the placement of the epidural catheter.~Then this will be followed by injection of 0.25% bupivacaine 15 ml as a single injection after induction of general anesthesia."